Lakeshore Village Nursing And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for four of six residents (Resident #11, Resident #43, Resident #53, and Resident #108) whose care was reviewed. The facility failed to allow Residents #11, #43, #53, and #108 to enjoy the salad bar that was served in the dining room because they either preferred to eat in their rooms or were bed ridden. This failure could place residents at risk of diminished feelings of self-worth and/or diminished quality of life. Findings included: Observation on 02/18/2025 at 12:54pm in the facility's 1 of 2 dining rooms revealed a kitchen aide serving hot dogs out of a crock pot, topping it with chili, cheese, and optional onions. When residents were being brought into the dining room by staff, or walking into the dining room, the aide would ask them if they wanted onions on their chili cheese dogs, and how…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences for 4 of 12 residents (Resident #9, Resident #11, Resident #43, and Resident #53) reviewed for food preferences. The facility failed to ensure Resident #9's lunch tray excluded gravy, in accordance with her dislikes which were listed on her meal ticket, on 02/20/2025 when the facility served Resident #9 two hamburger patties covered in brown gravy. The facility failed to ensure Resident #11's lunch tray included margarine and sweet and low, in accordance with her meal ticket as well as her preferences, (which were not listed on her meal ticket), on 02/18/2025, 02/19/2025, and 02/20/2025 and failed to include her coffee or tea on her lunch tray on 02/19/2025. The facility failed to ensure Resident #43's breakfast tray excluded oatmeal, in accordance with his dislikes that were not listed on his meal ticket on 02/20/2025 and failed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) for 1 of 4 residents (Resident #231) reviewed for ADL abilities. Resident #231's glasses were dirty and had built-up grime present to both lenses on 02/19/25. This deficient practice could place residents who required assistance at risk for not receiving care and services to meet their needs and avoid ADL decline. Findings included: Record Review of Resident #231's face sheet dated 02/20/25 reflected the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood), and hypertension (a long-term medical condition in which the blood pressure in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological's were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for two of five medication carts observed in that: Medication carts #1 and #2 were left unattended and unlocked. This failure could allow residents, staff and visitors unsupervised access to prescription and over-the-counter medications. Findings include: Medication Cart #1: An observation on 09/10/20224 at 5:10 am revealed Medication cart # 1 in Hall-B was against a wall across from the nurses' station, with the drawer's facing outward. The medication cart was unlocked and unsupervised. There were no residents and no staff within sight. Observation of the contents of the drawers revealed they contained prescription and over-the-counter medications. In an interview on 09/10/20224 at 5:12 am, LVN-A stated she had recently gotten something from the cart and forgot to lock it. The cart remained opened as LVN-A began to walk down the hall. In an interview on 09/10/20224 at 6:20 am,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of ten residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement and utilize facility abuse, neglect, exploitation, or misappropriation - reporting and investigating policies when they did not report to local, state, and federal agencies (as required by current regulations) allegations sent by a LPN via text message to the administrator. In the text, the LPN revealed she believed that Resident #2 ejaculated on Resident #1. The facility failed to identify and assess all possible incidents of abuse and investigate and report all allegations of abuse within timeframes required by federal requirements. This failure placed residents at risk of undetected abuse, trauma, and/or decline in feelings of safety and well-being or psychosocial harm. Findings included: Review of Resident #1's face…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made for 1 of 10 residents screened for abuse (Resident #1). The facility failed to immediately report to the State Agency (within 2 hours) an allegation sent by an LPN via text message to the administrator that she believed that Resident #2 ejaculated on Resident #1. This deficient practice delayed the investigation for the allegation and could have placed residents at risk for abuse and could have resulted in undetected abuse and/or decline in feelings of safety and well-being or psychosocial harm. Findings included: Review of Resident #1's face sheet dated 08/21/24 reflected a [AGE] year-old male, in the facility secured unit, who was admitted to the facility on [DATE] and readmitted on [DATE] with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure [NAME] A, Dishwasher C, and DA B wore hairnets and beard restraints when cooking, preparing, or assembling food. This failure could place residents who received meals and/or snacks from the kitchen at risk of foodborne illness due to physical contamination. Findings included: An observation of the dining room on 06/29/24 at 9:58 a.m. revealed [NAME] A walked out of the kitchen and into the dining room. [NAME] A was not wearing a beard restraint. Dishwasher C was also not wearing a hairnet when washing dishes at the dishwashing station in the kitchen. During an interview on 06/29/24 at 10:02 a.m., [NAME] A revealed he was not wearing a beard restraint, but he wore a hair net. [NAME] A stated food service staff were required to wear hairnets once they entered the kitchen. [NAME] A explained only food service staff on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident and to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 7 residents (Residents #2 and 3) reviewed for pharmaceutical services. 1. The facility failed to administer medications (dicyclomine, Eliquis, Zoloft, lactulose, levetiracetam, and enalapril maleate) to Resident #2 on time on 05/09/24, 05/10/24, 05/11/24, 05/12/24, 05/13/24, 05/14/24, and 05/15/24. 2. The facility failed to implement their controlled substances policy when they discovered a bottle of oxycodone in Resident #3's possession on 01/19/24 without an order in place. These failures placed residents at risk of not receiving medication therapies, overdose, and drug diversion. Findings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: *Food items were dated and sealed appropriately. *Expired food items were discarded. *The can opener was clean. *The microwave was clean *The juice nozzles were clean *The ice maker was clean *The mixer was clean *The deep fryer was clean *Hairnet worn correctly *Hydrion test strips (test strips used to measure the concentration of chemicals in sanitizing solution) were not expired. *Ecolab chlorine test strips (test strips used to measure the concentration of chemicals in sanitizing solution) were not expired These failures could place residents at risk for foodborne illness. Findings included: During an observation of the kitchen and interview on 12/11/2023, starting at 8:30 a.m., accompanied by the Dietary Manager the following observations were made: Refrigerator: *1 Sysco Reliance BBQ sauce with no open date or expire date *1 Worcestershire…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 7 of 7 meetings ( May 2023, June 2023, July 2023, August 2023, September 2023, October 2023, and November 2023) reviewed for QAPI. 1. The facility did not ensure the Infection Control Preventionist attended their QAPI meeting in May 2023, July 2023, August 2023, September 2023, October 2023, and November 2023. 2. The facility did not ensure the DON attended their QAPI meeting in June 2023. These failures could place residents at risk for quality deficiencies being unidentified, infections, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign in sheets indicated the Infection Preventionist did not sign in for their meetings from May 2023, July 2023, August 2023, September 2023, October 2023, and November 2023. Record review of the facility's QAPI Committee sign in sheets indicated the DON did not sign…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 3 of 6 residents (Resident #231, Resident #330, and Resident #333) reviewed for baseline care plans. 1. The facility failed to ensure Resident #333 had a baseline care plan completed within 48 hours of admission 2. The facility failed to ensure Resident #330's baseline care plan was signed by an RN. 3. The facility did not ensure Resident #231 baseline care plan was completed within 48 hours of admission and signed by an RN. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: 1. Record review of a face sheet dated 12/16/2023 indicated Resident #333 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (lungs cannot provide enough oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 8 of 33 residents reviewed for care plans. (Resident's #12, #25, #65, #101, #105, #107, #111) 1. The facility did not implement a care plan for Resident #12's seizure disorder. 2. The facility did not implement a care plan for Resident #65's seizure disorder. 3. The facility failed to ensure Resident #107's physician's order for 1800ml fluid restriction was implemented. 4. The facility failed to ensure Resident #25's comprehensive care plan addressed his incontinence of bladder and sippy cup. 5. The facility failed to ensure Resident #105's Apixaban (also known as Eliquis an anticoagulant medication) was included in his care plan. 6. The facility failed to include the diagnosis of constipation in Resident #101's care plan after his recent hospitalization for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to meet professional standards of care, for 3 of 6 residents (Resident #2, Resident #16, and Resident #40) reviewed for professional standards with medication administration. 1. The facility failed to ensure MA A performed hand hygiene while administering medications to Resident #2, Resident #16, and Resident #40. 2. The facility failed to ensure Resident #16 was administered the correct dose of Depakote (medication used to treat mood disorders). The facility failed to ensure Resident #16 was administered Medrol (steroid medication). These failures could place residents at an increased risk for inaccurate drug administration, not receiving the care and services to meet their individual needs, and the spread of infection. Findings included: 1. During an observation of medication administration beginning on 12/12/2023 at 8:12 AM, MA A administered medications to Resident #40. After administering medications to Resident #40 MA A did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 secured unit and 2 of 24 residents reviewed for activities on the secured unit. (Resident's #106 and #117) 1. The facility failed to ensure Resident #106, and Resident #117 received activities to meet their interests. 2. The facility failed to ensure activities were performed in the secured unit. 3. The facility failed to ensure the activity calendar was posted in the secured unit. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. The findings included: 1. Record review of the face sheet, dated 12/14/23, revealed Resident #106 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of dementia with mood disturbance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident and hazards as possible and provided supervision interventions to prevent avoidable accidents for 1 of 4 residents (Resident #111) reviewed for falls, and 1 of 2 smoking areas (secured unit smoking area), and 1 of 5 shower rooms reviewed (Hall 400 shower room). 1.The facility failed to ensure Resident #111 had her physician ordered fall intervention a fall mat beside her bed. 2. The facility did not ensure a metal container was available in the secured unit's smoking area to empty the ashtrays. 3. The facility failed to ensure the shower room door on the Hall 400 would closed securely. These failures could place residents at risk of injury from accidents and hazards. Findings included: 1. Record review of a face sheet dated 12/15/2023 indicated Resident #111 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] with the diagnosies of liver…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 5 of 10 (Residents # 48, #35, #6, #34, and #93) residents reviewed for respiratory care. 1. The facility failed to properly store the handheld nebulizer (HHN) and date tubing for Resident # 48 and Resident #35. 2. The facility did not ensure Resident #6 had an order from the physician to receive oxygen. 3. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #34. 4. The facility failed to ensure Resident #93's oxygen concentrator and filter were clean and free from debris. These failures could place residents requiring respiratory care at risk for respiratory infections or complications. Findings included: 1.Record review of Resident #48's face sheet, dated 12/16/23 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 4 of 33 residents (Residents #52, Resident #62, Resident #115, and Resident #339) and 1 of 1 facility reviewed for pharmacy services. 1. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to keep periodic reconciliation of Resident #339's Tramadol 50 mg tablets (controlled pain medication). 3. The facility failed to ensure MA C documented on the MAR and narcotic record the administration of Resident #52's Acetaminophen-Codeine 300-30 mg (controlled pain medication). 4. The facility failed to ensure Resident #115's Hydrocodone-Acetaminophen 5-325 mg (controlled pain medication) was accurately reconciled. 5. The facility failed to ensure Resident #61's seizure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 33 residents (Resident #16 and Resident #105) and 1 of 5 medication carts reviewed for drugs and biologicals. 1. The facility failed to ensure the Secured Unit medication cart was secured and unable to be accessed by unauthorized personnel. 2. The facility failed to ensure Resident #16's medication card matched the order for her Depakote (medication used to treat mood disorder). 3. The facility failed to ensure Resident #105's nasal spray was stored properly. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: 1. During an observation of medication administration on the secured unit on [DATE] beginning at 9:04 AM, RN B prepared medications for Resident #61. After preparing them she went…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 8 of 32 residents (Resident #15, #42, #65, #95, #100, #105, 111, and #333) and 1 of 1 meal (lunch meal) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature or taste to residents who complained the food was not hot and did not taste good. The facility failed to ensure Resident #111 received fortified foods. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: 1. During an observation and interview on 12/6/2023 starting at 1:15 p.m., a test lunch tray was sampled by the Dietary Manager and six surveyors. The sample tray consisted of parmesan crusted chicken patty with gravy, buttered spaghetti noodles, boiled zucchini, sliced strawberries with whipped cream. The parmesan crusted chicken patty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review the facility failed to follow their own established smoking policy for the 1 of 2 smoking areas (secured unit) reviewed for smoking policies. The facility did not ensure a metal container with a self-closing cover device was available in the secured unit's smoking area to empty the cigarette butts. This failure could place residents at risk of an unsafe smoking environment. The findings included: Record review of the resident's smoking policy, dated 09/2022, revealed metal containers, with self-closing cover devices, are available in smoking area and ashtrays are emptied only into designated receptacles. During an observation on 12/11/23 beginning at 10:29 AM, the smoking area in the secured unit had no metal trashcan to empty the ashtrays into. During an observation on 12/11/23 beginning at 4:01 PM, numerous, red-tipped cigarette butts were observed in the brown, plastic trashcan located outside with a plastic liner. No metal trashcan was observed. During an interview on 12/11/23 beginning at 4:07 PM, CNA O stated the ashtrays in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 33 residents (Resident #34) reviewed for resident rights. The facility did not ensure Laundry Aide F knocked, introduced herself, and explained what she was doing prior to entering Resident #34's room. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth. Findings included: Record review of a face sheet dated 12/16/2023 indicated Resident #34 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included acute on chronic diastolic (congestive) heart failure (heart does not pump blood as well as it should which can result in swelling, weakness, tiredness, and shortness of breath). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #34 was usually able to make herself…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 33 residents (Resident #68) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #68's call light was within reach. This failure could place residents at risk for unmet needs and decreased quality of life. Findings Included: Record review of Resident #68's face sheet dated 12/14/2023, indicated Resident #68 was a [AGE] year-old male admitted to the facility on [DATE], with diagnosis which included unspecified sequelae of cerebral infraction (residual effects or conditions produced after the acute phase of an illness or injury has ended), type 2 diabetes mellitus without complications (closely manages their type 2 diabetes, they can reduce their risk of developing any complications), hypertension (when the pressure in your blood vessels was too high (140/90…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 1 of 33 residents (Residents #61) reviewed for advanced directives. The facility did not ensure Resident #61's OOH-DNR included the legal guardian's signature, date, and printed name at the top of the form. The facility did not ensure Resident #61's OOH-DNR included the Notary information at the top of the form. These failures could place residents at risk of not receiving care and services to meet their needs. The findings included: Record review of the face sheet, dated [DATE], revealed Resident #61 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of epileptic seizures related to external causes (chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures) and severe intellectual disabilities (learning disability characterized by below average intelligence). Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide a safe, clean, and comfortable environment for 2 of 71 rooms reviewed. (Room #'s 45 and 331) 1. The facility failed to ensure resident room [ROOM NUMBER]'s heating unit was working. 2. The facility failed to ensure Resident #331's TV cable outlet was not out of the wall. These failures could place the residents at risk for a diminished quality of life and a diminished well-kept environment. Finding included: 1).Record review of a face sheet dated 12/16/2023 indicated Resident #45 was a [AGE] year-old male who originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure and high blood pressure. Record review of a Significant change MDS dated [DATE] indicated Resident #45 was understood and understands. The MDS indicated Resident #45's BIMS score was 15 indicating he had no problems with cognition. Record review of a Comprehensive care plan dated 8/31/2016 and a revision date of 12/14/2022 indicated Resident #45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 6 residents (Resident #52) reviewed for grievances. The facility did not ensure a grievance was completed for Resident #52's complaint of his television's poor reception being snowy. This failure could place residents at risks of grievances not being addressed or resolved promptly and a diminished quality of life. Finding included: Record review of a face sheet dated 12/16/2023 indicated Resident #52 originally admitted on [DATE] and readmitted on [DATE] with the diagnoses of end stage renal disease (kidney failure), and diabetes. Record review of a Quarterly MDS dated [DATE] indicated Resident #52 understands and was understood by others. The MDS indicated Resident #52's BIMS score was 15 indicating no problems with cognition. During an observation, and interview on 12/11/2023 at 9:20 a.m., Resident #52 turned on his television with the intent of showing the poor reception of his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #63) reviewed for discharge MDS assessments. The facility failed to ensure Resident #63's discharge MDS assessment was completed and transmitted. This failure could place residents at risk of not having records completed and submitted in a timely manner as required. Findings include: Record review of a face sheet dated 12/14/2023 indicated Resident #63 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). The face sheet indicated Resident #63 had a date of discharge to home of 07/24/2023. Record review of the Discharge Planning and Summary with an effective date of 07/24/2023 indicated Resident #63…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for 1 of 33 residents (Resident #105) reviewed for comprehensive care plans. The facility failed to ensure Resident #105's care plan was updated to indicate he no longer had a foley catheter. These failures could place residents at increased risk of not having their individual needs met, unnecessary procedures/treatment, and a decreased quality of life. Findings included: Record review of a face sheet dated 12/16/2023 indicated Resident #105 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic diastolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #105 was able to make himself understood and understood others. The MDS assessment indicated Resident #105 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 2 of 7 residents (Resident #'s 44 and 71). The facility failed to ensure Resident #44's fingernails were free of a black colored material. 1) The facility failed to ensure Resident #71's fingernails were trimmed and free of a black colored material. 2) These failures could place residents at risk for and a decreased quality of life. Finding included: 1) Record review of a face sheet dated 12/14/2023 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of stroke, with left-sided weakness, and need for assistance with personal care. Record review of an Annual MDS assessment dated [DATE] indicated Resident #44 was usually understood and usually understood others. The BIMS indicated Resident #44's had moderate cognitive impairment. The MDS in Section E - Behaviors,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2.Record review of Resident #68's face sheet dated 12/14/2023, indicated Resident #68 was a [AGE] year-old male admitted to the facility on [DATE], with diagnosis which included unspecified sequelae of cerebral infraction (residual effects or conditions produced after the acute phase of an illness or injury has ended), type 2 diabetes mellitus without complications (closely manages their type 2 diabetes, they can reduce their risk of developing any complications), and hypertension (when the pressure in your blood vessels was too high (140/90 mmHg or higher). Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated Resident #68 had a BIMS score of 1, which suggested severe cognitive impairment. The MDS assessment indicated Resident #68 was always incontinent of bowel and bladder. Record review of the care plan last revised 10/2/2023, indicated Resident #68 received extensive assistance with toilet use. During an observation on 12/14/2023 at 5:14 p.m., CNA SSS provided incontinent care to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that resident who wereare trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 6 residents (Resident #65) reviewed for trauma-informed care. The facility did not ensure Resident #65's trauma screening was completed upon admission to the facility. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings included: Record review of a face sheet dated 12/16/2023 indicated Resident #65 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of high blood pressure, chronic pain, and anxiety disorder . Record review of a Quarterly MDS dated [DATE] indicated Resident #65 was understood and understood others. The MDS indicated Resident #65's BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 6.25%, based on 2 errors out of 32 opportunities, which involved 1 of 6 residents (Resident #16) reviewed for medication administration. The facility failed to ensure MA A administered the correct dose of Depakote (medication used to treat mood disorders) on 12/12/2023. The facility failed to ensure MA A administered Resident #16's Medrol (steroid medication) on 12/12/2023. These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions. Findings included: Record review of a face sheet dated 12/12/2023 indicated Resident #16 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and major depressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assist residents in obtaining routine and emergency dental services to meet the needs of 1 of 33 (Resident #118) residents reviewed for dental services. The facility did not ensure Resident #118 received dental services for missing dentures. This failure could place residents at risk for oral complications, and/or weight loss, and a decreased quality of life. Findings included: Record review of Resident #118's face sheet, dated 12/15/2023, indicated Resident #118 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Record review of the admission MDS assessment dated [DATE], indicated Resident #118 sometimes understood others and sometimes made herself understood. The assessment indicated Resident #118 had a BIMS score of 6, which indicated severe cognitive impairment. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 of 3 (Resident #25) residents reviewed. The facility failed to provide Resident #25's physician-ordered sippy cup with each meal tray. This failure put residents at risk for decreased fluid intake, dehydration, and decreased quality of life. Findings included: Record review of Resident #25's face sheet, indicated he was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), Multiple sclerosis (MS) (a long-lasting chronic disease of the central nervous system), hypertension (high blood pressure), and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility. The facility did not update their facility assessment when they admitted Resident #231 with a LVAD (a device that is used in the treatment of end-stage heart failure). This deficient practice could affect the resident by not having the necessary resources to ensure appropriate care is provided. Findings included: Record review of the facility assessment dated [DATE] revealed it did not address residents who used a LVAD. Record review of Resident #231's face sheet, dated 12/15/2023, indicated Resident #231 was a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that was present over a long time). Record review of the physician order summary report dated 12/15/2023, indicated Resident #231 had a LVAD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #48) reviewed for hospice services. The facility failed to maintain Resident #48's hospice binder. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: 1. Record review of Resident #48's face sheet, dated 12/16/23 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Congestive heart failure(CHF), or heart failure, (a long-term condition in which your heart can't…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.